| | People with mobility impairments: Physical activity and quality of participationAbstract BackgroundWe sought to describe the characteristics of physical activity levels, health, community integration, and social participation of people with mobility impairments. MethodsBased on responses to a participation survey, respondents, located primarily in the Midwestern United States, were divided into 3 physical activity groups: high, low, and inactive. We chose a purposeful sample of 604 people with mobility limitations who had a diagnosis of spinal cord injury, multiple sclerosis, cerebral palsy, stroke, or poliomyelitis. The Participation Survey/Mobility (PARTS/M) was used to measure participation in 6 domains and 20 different activities, the Physical Activity and Health Status (SF-36) was used to measure health and quality of life, and the Reintegration to Normal Living Index (RNL) was used to measure integration into the community. ResultsPeople with mobility impairments who were identified as having a high level of physical activity reported greater participation, better health, and a higher level of reintegration to normal community living compared with participants who described their physical activity level as low or inactive. ConclusionPositive health status and superior community participation were found in a high physical activity group compared with low active or inactive groups of people with mobility impairments and limitations. Despite proven benefits in health and quality of life associated with moderate daily exercise, over half of Americans currently do not participate in regular physical activity [1]. Furthermore, Americans with disabilities are less likely to engage in physical activity than those without disabilities, yet have greater need to promote health and prevent disease [2], [3]. An estimated 13% to 20% of the Western world's population has 1 or more disabilities, and 56% of this population does not participate in physical activity compared with 36% of the able-bodied population [3], [4]. According to the U.S. Department of Health and Human Services (USDHHS) Centers for Disease Control and Prevention (CDC), appropriately high levels of physical activity can be achieved in 1 of 2 ways. The first is through engagement in 30 minutes of moderately intense activity 5 days a week, resulting in a small increase in heart rate and burning 3.5 to 7 calories per minute. The second is by performing 20 minutes of vigorous activity 3 days a week, resulting in a large increase in heart rate and burning more than 7 calories a minute. These gains can be accomplished through activities such as house cleaning or yard work, as well as through traditional exercise and active recreation. Two additional classifications are used to characterize lower levels of physical activity. Insufficient physical activity is defined as engaging in more than 10 total minutes per week of moderate or vigorous intensity activities but less than the recommended level of activity previously defined. Inactivity is described as engaging in less than 10 total minutes per week of moderate or vigorous intensity lifestyle activities. These operational definitions are based on those used by the American Heart Association [5], [6]. Many studies have documented a variety of health benefits that result from increased physical activity. Moderate to high levels of physical activity have been demonstrated to increase strength, stamina, fitness, mobility, coordination, endurance, posture, weight control, immune function, cardiopulmonary function, and circulation for people with disabilities [7], [8], [9], [10], [11]. In addition, the psychological benefits of moderate levels of physical activity include a better acceptance of disability, a more independent attitude, enhanced mood, greater sense of life control, and fewer suicidal tendencies due to decreased depression and anxiety [7], [8], [9], [12], [13], [14]. Overall, health benefits due to moderate to high levels of physical activity include a decrease in secondary conditions and the need for medical care, as well as an increase in functional independence, energy, and physical capacity [13], [15], [16], [17], [18]. Subjectively, people who participate in physical activity report having a greater self image and level of self-satisfaction, increased feelings of well-being, and improved self-esteem, perceived health, body image, and self-resilience [9], [11], [19], [20], [21]. Although relationships between activity level and both the physical and psychological health status have been examined for people with disabilities [2], [21], [22], [23], [24], the participation in major life activities by people with mobility impairments who are inactive, somewhat active, or highly active has not been studied. The International Classification of Functioning, Disability, and Health (ICF) defined participation as involvement in some area of human life [26]. In 2003, Perenboom and Chorus [27] reviewed 11 instruments that have been reported to measure participation as defined by the ICF. Many existing measures are based on the concept of handicap as described in the 1980 version of the International Classification of Impairment, Disability, and Handicap [28]. Perenboom and Chorus assert that these measures are inadequate to assess the ICF concept of full participation. The term involvement, used by the ICF to define participation, allows for the expansion of the concept of participation beyond the frequency of doing activities or being limited in doing activities. Gray et al. [25] used the ICF concept of full participation as a basis for developing a measure of participation called the Participation Survey/Mobility (PARTS/M). The PARTS/M includes 6 of the 9 major life activities encompassed in the ICF. In addition to the temporal component of participation, the PARTS/M provides information on how individuals evaluate their participation, the influence of several health-related conditions on their participation, and the type and amount of support they use when they participate. The purpose of this study was to describe levels of physical activity and participation in major life activities as measured by the PARTS/M, health status as measured by the Physical Activity and Health Status (SF-36) Physical and Mental Health Summary Scales, and return to normal community life as measured by the Reintegration to Normal Living Index (RNL). Methods  Participants This study consisted of a purposeful sample of people with lower limb impairments who reported using a mobility device or having difficulty walking a distance of 3 city blocks. Inclusion criteria required that participants live in the community, have no history of mental illness, are able to give informed consent, and are over the age of 18. Non-English speakers, persons who did not use a mobility device or have difficulty walking 3 blocks, and persons who lived in institutions were excluded from the study. Participants were recruited from across the United States with the assistance of disability organizations, independent living centers, and support groups. All phases of this project were approved by the Washington University Human Subjects Committee. Instruments The PARTS/M is a self-report survey instrument designed to measure the participation of persons with mobility impairments in major life activities [25]. Six domains and 20 different activities are included in the PARTS/M (Table 1). Four components of participation (temporal, evaluative, health-related, and supportive) are included in each activity. Temporal questions focus on frequency of, and time spent participating in, an activity. Evaluative items are on choice, satisfaction, and importance of participating in a particular activity. Health-related questions ask if an activity is limited by illness, physical impairment, pain, fatigue, or another condition. Finally, the level of personal and/or environmental supports needed to perform an activity is solicited. Participation scores may be calculated for all 20 activities, the 6 domains, the 4 components, and an overall total. The internal consistency and stability of the PARTS/M are moderate to high [25]. The SF-36 consists of 8 subscales measuring physical and mental health with established reliability and validity for the general population [29]. Scores for each subscale range from 0 to 100; higher scores indicate better health status, except for the pain subscale, where low scores indicate that pain impedes doing activities. For this study, only 7 of the 8 subscales of the SF-36 were analyzed. The Physical Functioning (PF) subscale was excluded because these items ask questions about walking, lifting, climbing, and bending; these activities may not be possible for some people with mobility impairments [30]. The RNL is an 11-item instrument that assesses personal satisfaction with community integration and performance of everyday occupations [31]. High levels of satisfaction with community integration are indicated by high scores. This index is a valid measure of community integration for people living with chronic health conditions such as mobility impairments [32]. Procedures The PARTS/M, SF-36, RNL and demographic questionnaires were completed by 604 people with mobility impairments. The USDHHS-recommended amounts of physical activity were used to guide the formation of 3 physical activity groups: high active, low active, and inactive. These physical activity level groups were based on responses to questions regarding (1) frequency and duration of exercise inside the home, (2) frequency and duration of exercise outside of the home, and (3) frequency of participation in active recreation outside of the home (Table 2). Active recreation included activities such as swimming, golfing, playing basketball, skiing, racing, bowling, camping, going on nature trails, or other activities. | ∗ Includes those who responded “don't know” or “not applicable.” |
Data analysis Chi square tests were used to relate physical activity level with the demographic groups of race, level of education, gender, diagnostic group, annual income, type of primary mobility device utilized, and employment. A 1-way analysis of variance (ANOVA) was performed to compare the level of physical activity with participant age and the participation across the 6 participation domains. An ANOVA was used to examine relationships between physical activity groups and the subscales of the SF-36 and questions on the RNL. If results were significant at the .05 level, then Scheffé post-hoc tests were performed to analyze pairwise differences. Results Demographics The sample included 604 participants with lower limb impairments hindering their abilities to walk (Table 3). The distribution of device use by study participants was as follows: cane, crutch, walker (37%); power wheelchair (17%); manual wheelchair (14%); scooter users (15%); and those who reported having difficulty walking 3 or 4 city blocks but did not use a mobility device of any kind (17%). The sample included polio survivors (28%), stroke survivors (13%), individuals with a spinal cord injury (SCI) (23%), multiple sclerosis (MS) (21%), and cerebral palsy (CP) (15%). | | |  | Characteristic | Total | High active | Low active | Inactive | |
|---|
| N | 604 | 236 | 203 | 165 | | | Percent of sample | 100 | 39 | 34 | 27 | | | Gender | | |  Female | 57.5 | 55 | 51 | 68 | | | Male | 42.5 | 45 | 48 | 32 | | | Mean age (y) | 55.4 | 52 | 49.6 | 50.8 | | | Race | | | White/Caucasian | 88 | 89 | 87 | 89 | | | Black/African American | 10 | 8 | 12 | 9 | | | Other | 2 | 3 | 1 | 1 | | | No response | 0 0 | 0 | 1 | | | | Annual income | | | <$10,000 | 20 | 15 | 16 | 21 | | | $10,000 to <$25,000 | 30 | 20 | 29 | 28 | | | $25,000 to <$50,000 | 24 | 23 | 20 | 20 | | | $50,000 to $75,000 | 14 | 11 | 12 | 14 | | | >$75,000 | 13 | 15 | 10 | 7 | | | No response | 0 | 16 | 14 | 10 | | | Highest level of education | | | None to Grade 8 | 4 | 3 | 3 | 7 | | | Grade 9-11 | 4 | 4 | 4 | 4 | | | Grade 12 or GED | 30 | 25 | 28 | 36 | | | College 1-3 y | 27 | 29 | 26 | 25 | | | College ≥4 y | 35 | 36 | 38 | 26 | | | No response | 0 | 3 | 1 | 2 | | | Employment | | | Employed | 27 | 29 | 27 | 20 | | | Not employed | 73 | 69 | 71 | 75 | | | No response | 0 | 2 | 2 | 5 | | | Diagnostic group | | | SCI | 23 | 25 | 27 | 17 | | | MS | 21 | 20 | 19 | 23 | | | CP | 15 | 20 | 15 | 7 | | | Polio | 28 | 22 | 28 | 37 | | | Stroke | 13 | 14 | 11 | 16 | | | No response | | | | | | | Primary mobility device | | | Cane, crutch, walker | 37 | 38 | 36 | 36 | | | Power wheelchair | 17 | 15 | 17 | 17 | | | Manual wheelchair | 14 | 14 | 14 | 14 | | | Scooter | 15 | 15 | 14 | 18 | | | None | 17 | 18 | 19 | 15 | | | | |
The responses to the PARTS/M questions on exercise and active recreation were used to create 3 physical activity groups: 39% (n = 236) in high active, 34% (n = 203) in low active, and 27% (n = 165) in inactive. Significant differences were found for levels of physical activity when examined for diagnoses (p = .001), gender (p = .003), and age (p < .001). Those with CP and SCI were significantly more active than those who had MS or had survived a stroke or polio. More females were in low and inactive groups. The average age of those in the high active and low active groups was lower than the age of those in the inactive group. Physical activity and participation measured by the PARTS/M An ANOVA was used to examine the relationship between physical activity level and the 4 participation components of each of the 6 domains measured by the PARTS/M. A Scheffé post-hoc test revealed pairwise differences within each participation component (Table 4). Table 4 provides information on activity group differences. The frequency of participation (temporal) in the mobility domain and in the community, social, and civic life domain was significantly higher for those people in the high active group compared with the less active groups (p < .01 for each comparison). People in the high active group evaluated their participation as having higher choice and satisfaction in the self-care domain (p < .05), the mobility domain (p < .01), the domestic life domain (p < .01), and the community, social, and civic life domain (p < .01). The health-related domain, which assessed the influence of pain, fatigue, illness, and impairment upon participation, showed no group differences. The support used to participate (personal assistance and special equipment) was higher for the inactive group in the mobility and domestic life domains (p < .05 and p < .01, respectively). The total mobility domain scores for the high active group were larger than the low active group (p < .01) and the inactive group (p < .01). For the total domestic life domain, the high active group had a larger mean value than the low active group (p < .05) and the inactive group (p < .01). The total participation score for all domains was significantly higher for the high active group compared to the inactive group (p < .05). Physical Activity and Health Status (SF-36) The scores of the 3 physical activity groups on the 7 subscales of the SF-36 were compared using an ANOVA. The 7 subscales were role physical, mental health, role emotional, social functioning, vitality, general health, and bodily pain. The results of the analysis showed significant differences (p < .05) for physical activity groups for the social functioning, vitality, general health, and bodily pain subscales (Table 5). In addition, Scheffé post-hoc tests were conducted to analyze pairwise differences within each subscale. In the social functioning subscale, the inactive group was significantly lower than the high active group (p < .01). For the vitality subscale, the inactive group mean score was significantly lower than both the low active group and the high active group (p < .01). The general health subscale scores were lower for the inactive and low active groups than the high active group (p < .05). Finally, the inactive group mean for bodily pain was significantly lower than the low active group (p < .05) and high active group (p < .01). The low scores of the inactive group on the pain subscale signify that pain hinders the performance of activities. Physical activity and reintegration to normal living An ANOVA was used to examine the differences between physical activity level and each of the 11 questions contained in the RNL. Scheffé post-hoc tests were conducted to determine pairwise differences within these specific questions (Table 6). The high active group took more trips out of town and had a higher level of satisfaction with assistance provided for self-care (e.g., dressing, eating) than the inactive group (p < .01 for each comparison). Participants in the low active group spent more days participating in enjoyable work than those who were in the inactive group (p < .05). Members of the high active group scored higher than the low active for recreational activities (p < .05). The high active group participated more in social activities than the inactive group (p < .01). The low active group participated more in social activities than the inactive group (p < .01). Discussion This study used 3 instruments to investigate different aspects of the lives of people with mobility impairments who were grouped by their level of activity in exercise and recreation. The PARTS/M survey results indicate that people who often engage in physical activity participate in other major life activities more frequently than those who are less physically active. These findings are similar to Hanson et al. [17], who found that individuals with disabilities who participate in sports also demonstrate high levels of community participation. When asked to evaluate the quality of their participation, people in the higher active groups reported greater choice, satisfaction, and importance in major life activities and self-care domain activities than the inactive group members. The high active group described having more choices and satisfaction and using less support when participating in mobility and domestic life activities than did the low active and inactive groups. The interpersonal interactions and relationships domain of the PARTS/M showed a higher total participation score for the high active and low active groups than for the inactive group. No group differences were found in the major life areas domain. Participants in the high active group participated in the community, social, and civic life activities more frequently than both the low active and inactive groups. The total PARTS/M participation score for the high active group was significantly greater than the inactive group, which confirms the hypothesis that people who are classified as highly active in exercise and active recreation report higher levels of participation in others major life activities. Diagnostic group differences in reported activity level may be due to age. The majority of participants with SCI and CP were in the 31- to 40-year age group, while those who were stroke or polio survivors were in the 51- to 60-year age range. An ANOVA showed that those who reported high and low physical activity levels were significantly younger than those who reported being inactive (p < .01). Females with mobility impairments reported engaging in less physical activity than males with similar mobility impairments. The SF-36 was used to examine group differences in the general health status of the 3 activity groups. Compared with the low activity groups, people in the high active group report higher SF-36 scores on social functioning, vitality, and general health subscales. The inactive group scored lower on the pain subscale than the high active and low active groups, indicating that this group experienced severe and very limiting pain. These findings support the assertion made in Healthy People 2010 that physical activity of people with mobility impairments and health status are related [3]. Both the PARTS/M and RNL measures found that members of the high active group took more out-of-town trips, did more of their own self-care, were more likely to be employed, and participated more frequently in recreational and social activities than did people in the low active and inactive groups. Study limitations The 3 physical activity level groups were formed retrospectively using criteria applied to data collected about subjectively reported levels of exercise and active recreation. Thus, causal relationships among health, activity level, and social participation cannot be made. A majority of the significant differences in participation were reported for comparisons of the high active and inactive groups, which may mean that differences in physical activity level may only be associated with participation differences for the most active and least active people with mobility impairments. Differences among activity groups using the PARTS/M were not always confirmed when the RNL was used. For example, differences in self-care for the 3 activity level groups were found when the RNL was used but not when the PARTS/M was used. Finally, the sample was a purposive group of people with mobility impairments and does not reflect a national random sample of the total population of people living with mobility impairments, which limits the generalization of these findings. Conclusion Individuals with mobility impairments who report a high level of physical activity evaluate participation in social activities higher than those who are less physically active. These relatively high active individuals describe their health status as better than those in the low and inactive groups. Several indicators of positive integration into normal community living were found more frequently in the high active group. These results need to be examined for causal relationships to discover if community-based health and wellness interventions have a salutary influence on the quality of participation of those receiving the intervention. The findings of our study strongly suggest that measures of health status need to be supplemented by measures of community participation. Use of multiple measures could extend outcome measurement beyond clinical settings to environments where people live. Providing community based programs that focus on increasing the level of physical activity of people with mobility impairments and limitations may improve their health and community participation, which are important goals for the rehabilitation industry, for individuals with disabilities, and for our society. 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Program in Occupational Therapy and Department of Neurology, Washington University, School of Medicine, St. Louis, MO 63108, USA  Corresponding author: 4444 Forest Park, St. Louis, MO 63108. Fax: 314-286-1601.
PII: S1936-6574(07)00006-4 doi:10.1016/j.dhjo.2007.11.004 © 2008 Elsevier Inc. All rights reserved. | |
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